Mobility and ART retention among men in Malawi: a mixed methods study

Abstract

Introduction: Mobility is associated with worse outcomes across the HIV treatment cascade, especially among men. However, little is known about the mechanisms that link mobility and poor HIV outcomes and what types of mobility most increase the risk of treatment interruption among men in southern Africa. Methods: From August 2021 - January 2022, we conducted a mixed-methods study with men living with HIV (MLHIV) but not currently receiving antiretroviral therapy (ART) in Malawi. Data collection was embedded within two larger trials (ENGAGE and IDEaL trials). We analyzed baseline survey data of 223 men enrolled in the trials who reported being mobile (defined as spending >14 nights away from home in the past 12 months) using descriptive statistics and logistic regression. We then recruited 32 men for in-depth interviews regarding their travel experiences and ART utilization. We analyzed qualitative data using constant comparative methods. Results: Survey data showed that 34% of men with treatment interruptions were mobile, with a median of 60 nights away from home in the past 12 months; 69% of trips were for income generation. More nights away from home in the past 12 months and having fewer household assets were associated with longer periods out of care. In interviews, men reported that travel was often unplanned, and men were highly vulnerable to exploitive employer demands, which led to missed appointments and ART interruption. Men made major efforts to stay in care but were often unable to access care on short notice, were denied ART refills at non-home facilities, and/or were treated poorly by providers, creating substantial barriers to remaining in and returning to care. Men desired additional multi-month dispensing (MMD), the ability to refill treatment at any facility in Malawi, and streamlined pre-travel refills at home facilities. Conclusions: Men prioritize ART and struggle with the trade-offs between their own health and providing for their families. Mobility is an essential livelihood strategy for MLHIV in Malawi, but it creates conflict with ART retention, largely due to inflexible health systems. Targeted counseling and peer support, access to ART services anywhere in country, and MMD may improve outcomes for mobile men.

Mobility and HIV care engagement: a research agenda

“…We recently assessed the impact of mobility on ART adherence (measured by levels of ART in hair samples) in communities in the Lake Victoria region and found that longer trips (>1 month) were associated with lower ART adherence as compared to shorter trips [ 54 ]. We also conducted qualitative research with mobile men in Malawi and found that men's control (or agency) over travel departure and duration greatly impacted how mobility interacted with HIV care [ 55 ]. Men emphasized that unplanned travel was unavoidable due to limited cash‐earning opportunities at home; they had no choice but to travel wherever employment was available and for whatever duration an employer demanded.…”

“…For example, should interventions target people in extreme poverty who have limited employment opportunities, or those with more education who seek better job prospects in cities [ 57 , 58 ]? Many men in SSA depend on mobility, but men who experience relative and absolute poverty often participate in more chaotic, less predictable mobility in pursuit of work [ 55 ], and disaggregating this broad group of “mobile men” could help target future interventions.…”

Migrant men and HIV care engagement in Johannesburg, South Africa

“…30 The heterogenous nature of population mobility and varying definitions of migration further complicate efforts to understand migration and healthcare engagement, especially across different settings and populations. 31,32 For example, some studies focus on the temporal nature of mobility (e.g., seasonal migration 33 ), while others focus on specific social reasons for mobility (e.g., market traders 34 or miners 35 ), or spatial aspects of mobility, such as how distance traveled affects HIV acquisition risk. 36,37 In addition, there are challenges accessing migrant men in research.…”